Systems Analysis and Improvement Approach to Optimize the Hypertension Diagnosis and Care Cascade for HIV-infected Individuals (SAIA-HTN)

未经诊断和治疗的高血压(HTN)是心血管疾病的最大驱动因素之一 (CVD)在撒哈拉以南非洲(SSA)。跨SSA、基于证据的临床指南进行筛查和管理 存在高血压；但是，由于缺乏服务准备，国家一级的应用水平较低且不均衡， 卫生工作者动机参差不齐，缺乏对卫生工作者业绩的问责，整合能力差 将HTN筛查和管理与慢性护理服务结合起来。在莫桑比克-像许多国家一样 艾滋病毒负担高-艾滋病毒治疗平台是第一个广泛实施的慢性护理服务。使用 大量患者接受抗逆转录病毒治疗(莫桑比克为85万人)，这是一种独特的 使高血压筛查和管理标准化和规模化的机会。低成本、系统级 干预措施是改善相互关联的级联服务的有效和高效的方法，并且可能 有效地使现有慢性护理服务中的HTN诊断和管理常规化； 解决个人和系统层面的障碍；改善HTN级联的流动；以及 最终改善患者水平的结果。 系统分析和改进方法(SAIA)旨在优化级联性能， 对于一线医护人员和管理人员是可行的，并适用于优化HTN检测和 艾滋病毒携带者(PLHIV)在多种情况下的治疗级联。我们已经成功地进行了试验 SAIA用于针对PLHIV的HTN级联，以及随着HTN筛查和管理被纳入慢性病的主流 SSA(包括莫桑比克)的护理服务，展示了SAIA-HTN作为 适应性强、可扩展的模型，便于广泛实施。SAIA-HTN的总体目标是评估一个模型 为系统地评估和改进艾滋病病毒感染者的HTN诊断和管理服务 莫桑比克。我们的具体目标是：(1)确定SAIA-HTN对HTN级联的有效性 优化HIV感染者；(2)确定实施SAIA-HTN干预的驱动因素 设施之间的异质性；(3)确定SAIA-HTN用于护理级联的成本和成本效益 优化。我们将部署一项整群随机试验来评估SAIA-HTN干预的影响 关于8个干预机构和8个控制机构的高血压管理。有效性将通过以下方式衡量 针对PLHIV和HTN以及HIV临床结局的HTN级联流动措施。干预成本将是 从付款人的角度进行评估(例如卫生部)，并进行成本效益分析，以估计 通过HTN级联步骤的额外患者的增量成本，以及每个额外的成本 伤残调整生命年(DALY)。实施过程将使用焦点小组进行描述 利用执行综合框架分析的讨论和主要线人访谈 研究，使用来自研究日志的补充数据来描述对SAIA-HTN干预设计的保真度。

Undiagnosed and untreated hypertension (HTN) is one of the largest drivers of cardiovascular disease (CVD) in sub-Saharan Africa (sSA). Across sSA, evidence-based, clinical guidelines to screen and manage hypertension exist; however, country level application is low and uneven due to lack of service readiness, uneven health worker motivation, lack of accountability for health worker performance and poor integration of HTN screening and management with chronic care services. In Mozambique – like many countries with high HIV burden – the HIV treatment platform was the first broadly implemented chronic care service. With large numbers of patients on anti-retroviral treatment (850,000 in Mozambique), it presents a unique opportunity to standardize and scale hypertension screening and management. Low-cost, systems level interventions are effective and efficient approaches to improve linked cascade services, and may be effective for routinizing HTN diagnosis and management within existing chronic care services; addressing both individual and systems-level barriers; improving flow through the HTN cascade; and ultimately improving patient level outcomes. The Systems Analysis and Improvement Approach (SAIA) is designed to optimize cascade performance, is feasible for frontline healthcare workers and managers, and is applicable to optimize the HTN testing and treatment cascade for people living with HIV (PLHIV) across multiple contexts. We have successfully piloted SAIA for the HTN cascade for PLHIV, and as HTN screening and management is mainstreamed into chronic care services in sSA (including in Mozambique), demonstrating SAIA-HTN potential effectiveness as an adaptable, scalable model for broad implementation. The overall goal of SAIA-HTN is to evaluate a model for systematic assessment and improvement of HTN diagnosis and management services for PLHIV in Mozambique. Our specific aims are to: (1) Determine the effectiveness of SAIA-HTN on HTN cascade optimization for HIV-infected individuals; (2) Determine the drivers of SAIA-HTN intervention implementation heterogeneity across facilities; (3) Determine the costs and cost-effectiveness of SAIA-HTN for care cascade optimization. We will deploy a cluster randomized trial to evaluate the impact of the SAIA-HTN intervention on hypertension management in 8 intervention and 8 control facilities. Effectiveness will be measured via HTN cascade flow measures for PLHIV and HTN and HIV clinical outcomes. Intervention costs will be assessed from the payer perspective (e.g. MOH), and cost effectiveness analysis conducted to estimate the incremental costs for additional patients passing through the HTN cascade steps, and the cost per additional disability-adjusted life year averted (DALY). The implementation process will be described using focus group discussions and key informant interviews analyzed using the Consolidated Framework for Implementation Research, with complementary data from study logs to describe fidelity to the SAIA-HTN intervention design.